Provider Demographics
NPI:1932716172
Name:JEFFERSON, JAMES VAN (LISW)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:VAN
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:VAN
Other - Last Name:JEFFERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW
Mailing Address - Street 1:PO BOX 740013
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0013
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:5110 FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-4323
Practice Address - Country:US
Practice Address - Phone:803-893-7019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
SC15512104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker